Quote Request

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This form can be printed, filled in by hand and then mailed to ManifestMarine at the address above, or it can be faxed (call the number above to obtain the fax number.) It can also be filled in on your computer and then either printed and mailed or faxed to us, or the form can be e-mailed to . In any case, we look forward to being of service.

Personal Information

The personal information you provide will not be used by Manifest Marine or the insurers it represents except for the purpose of determining the present availability and cost of the insurance you specify below. Someinsurers we represent check driving, claims and credit histories in order to determine the availability and cost of their insurance; please mention in the Comments section if you do not wish to consent to this. The contact information you provide will not be used by us or others to contact you again at a later time unless you choose to have Manifest Marine arrange such insurance for you.
Name of applicant
Mailing address / (include the city, state and postal code
of your address, and, if it is outside the
U.S.A., include the country.)
Telephone / Fax / E-mail
Occupation / (if retired please also indicate prior occupation)
Citizenship / Driver license / (number and issuer)
Date of birth / Years boating / Years as boatowner
Largest prior vessel / (describe vessel, years owned and where operated)
Second largest vessel / (describe vessel, years owned and where operated)
Boating courses taken / (please also list any boating licenses held)
Place a check next to any of the following statements that are true:
I have been cited for a boating or motor vehicle violations in the past five years.
I have made an insurance claim against a boat or motor vehicle insurance policy in the past five years.
I have been denied an insurance policy by an insurance company for boat or motor vehicle insurance.
I have had a boating or motor vehicle license suspended or revoked.
I have been convicted of a felony.
Someone will operate the vessel on a regular basis without me aboard.
A captain or crewman will be hired to operate or assist in the operation of the vessel.

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If any statement was checked, please provide details of the relevant circumstances in the Commentssection at the end of this form.

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Vessel Information

Owners / applicant only / (if other than applicant named above)
Name / Builder
Model / Style / SELECTsloopcutterketchyawlschoonertrimaransailing catamaranpower catamaranmotorsailertrawlersemi-displacement trawlermotoryachtconvertiblesportfishermansedancruiseroffshore raceboatexpressrunaboutcenter consolebass boatdeck boathouseboatother
Year / Length / Construction / SELECTfiberglassaluminumsteelwoodcold-molded epoxycarbon fiberferrocementother
Place Built / Place Registered
Propulsion / Type:SELECTinboardI/Ooutboardjetsail onlymanualnoneother Gasoline Diesel Year/Manufacturer:
Single Twin Triple HP each: Maximum MPH:
Equipment / Automatic fire extinguisher Fume detector Theft alarm High water alarm
RADAR VHF radio Depthsounder LoRan GPS
Dinghy with motor Dinghy w/o motor Liferaft Trailer
Particularly if the vessel will be traveling internationally, please describe any additional safety, navigation or other equipment aboard or other preparations you have made to enhance the seaworthiness of the vessel and the safety of its crew.
Spars / nonealuminumsteelwoodcarbon fiberother / Rigging age / original / (for sailboats, please specify material of the spars and age of standing rigging)
Damage / none / (please describe any existing damage or other faults of the vessel)
Survey / none / (indicate date of latest professional survey and whether or not the vessel was ashore for this)

Usage Information

Type of use / Recreational Liveaboard Racing Trailering Waterskiing
Bareboat charter Crewed charter Commercial use other than charter
Time of use / Year-round use
Kept in portFrom: Until:
Stored ashoreFrom: Until:
Area of use / Coastal waters Between: And:
Nontidal waters of U.S. Bahamas Cuba Caribbean Mexico Canada
Great Lakes San Francisco Bay Puget Sound Chesapeake Bay
Other:
Mooring / Regularly cruising
Year-roundAt:
SeasonalWinter at: Summer at:

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Coverage Information

Present insurer of vessel / n/a (new purchase) / Expiration date of policy / n/a
Purchase cost of vessel / Date ofpurchase
Estimated current value / same as purchase cost / (if higher than purchase cost, describe why in Comments section below)
Desired insurance amount / same as current value / (if other than current value, describe why in Comments section below)
Deductible / 1% 2% 3% 4% 5% 10% (percentage of insurance amount)
Value of dinghy & motor / n/a / (include in current value)
Value of trailer / n/a / (include in current value)
Liability insurance / $300,000 $500,000 $1,000,000 other:

Comments

Please use the space below to expound upon any of the information provided above or to advise us of any peculiar circumstances of which we should know. If any use other than recreational was indicated above, please provide below details of the planned use. Please also use the space below to specify any supplemental coverages in which you are interested.
Please let us know how you came to learn about Manifest Marine:

Quote Request

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